Choice Plan - Express Scripts

DrugNameDrugTierRequirements/LimitsROXICET ORAL SOLN 2 QL(5580per 90 days)MOstagesic 1 GC QL(720per 90 days)MOvicodin 1 GCQL(1080per 90 days)MOvicodin es 1 GCQL(1080per 90 days)MOvicodin hp 1 GCQL(1080per 90 days)MONON-NARCOTIC ANALGESICSARTHROTEC 50 3 MOARTHROTEC 75 3 MObuprenorphine hcl/naloxone hcl 1 GC MObutorphanol tartrate nasal soln 1 GC PAQL(30 per90 days)MOCELEBREX 2 QL(180 per90 days)MOdiclofenac potassium 1 GC MOdiclofenac sodium dr 1 GC MOdiclofenac sodium er 1 GC MOdiclofenac sodium/misoprostol 1 GC MOdiflunisal 1 GC MOetodolac 1 GC MOetodolac er 1 GC MOfenoprofen calcium 1 GC MOFLECTOR 3 MOflurbiprofen 1 GC MOibuprofen susp 1 GC MOibuprofen tabs 400mg, 600mg, 1 GC MO800mgindomethacin caps 1 GC MOindomethacin er 1 GC MODrugNameDrugTierRequirements/Limitsketoprofen 1 GC MOketoprofen er 1 GC MOmeclofenamate sodium 1 GC MOmefenamic acid 1 GC MOmeloxicam 1 GC MOnabumetone 1 GC MOnaloxone hcl inj 1mg/ml 1 GC MOnaltrexone hcl 1 GC MOnaproxen 1 GC MOnaproxen dr 1 GC MOnaproxen sodium tabs 275mg, 1 GC MO550mgNUCYNTA 2 QL(541 per90 days)MONUCYNTA ER 2 QL(180 per90 days)MOoxaprozin 1 GC MOPENNSAID 2 MOpiroxicam 1 GC MOSUBOXONE 2 MOsulindac 1 GC MOtolmetin sodium 1 GC MOtramadol hcl 1 GC QL(720per 90 days)MOtramadol hcl er tb24 2 QL(90 per90 days)MOVIMOVO 2 QL(180 per90 days)MOVOLTAREN GEL GEL 2 MOPSYCHOTHERAPEUTIC DRUGSABILIFY DISCMELT TBDP15MG3 QL(180 per90 days)MOABILIFY DISCMELT TBDP10MG3 QL(270 per90 days)MOABILIFY INJ 3 MO14